Debating DSM-5

Last month the British Psychological Society’s division of clinical psychology (DCP) issued a statement attacking the dominant bio-medical models of mental illness. Lucy Johnstone, a clinical psychologist who was one of the architects of the DCP’s statement, said: ‘There is now overwhelming evidence that people break down as a result of a complex mix of social and psychological circumstances – bereavement and loss, poverty and discrimination, trauma and abuse.’

The DCP’s statement was a pre-emptive strike on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which was published a couple of days later. The categorisations of human experience promoted by the various editions of the DSM have been immensely influential across the world. If you visit a shrink for reasons to do with what you might refer to as your ‘mental health’, it’s quite likely that he or she will be working within DSM diagnostic criteria and may even have one in mind for you. GPs, never afraid to diagnose and medicate mental states, can use DSM definitions pretty freely too. Given the modern history of the US in establishing political hegemonies and practices of cultural dominance, this is something of a worry. Millions of people are diagnosed, treated and medicated according to imperial American psychologies.

The DSM-5’s publication has generated something of a backlash, as professionals and non-professionals – using an internet that wasn’t available when DSM-4 appeared – articulate what everyone has known for yonks: that the DSM is unreliable, unsafe and promotes models of mental health that look positively Orwellian.

Lucy Johnstone’s implicit definition of mental illness foregrounded poverty, discrimination, loss and abuse; all states that neoliberalism facilitates and perpetuates. These are not factors that classical taxonomies of pathology have sought to embrace. And for good reason.

Descriptions of mental illness can very often be typologies of cruelty, an interpretation of someone’s identity that they haven’t participated in but have to submit to. The mental health profession has historically been ridiculously easy to recruit by totalitarian or colonial systems seeking to pathologise dissidence or difference.

Even as a diagnostic tool, biomedical models such as the DSM can be worse than useless. Anders Breivik was examined by two different psychiatric teams who came to completely different conclusions. They couldn’t agree if he was psychotic or not. They were asking a question that was beside the point.

Even Noddy could tell you that murdering 77 defenceless children and adults is probably not a sign of sanity. But it is the political conditions that enabled Breivik, and how they fired up his personal pathology, that are of critical interest.

The other night I was listening to Benjamin Britten’s opera Peter Grimes (violent child-abusing fisherman battles with toxic bigoted villagers) one of the three operas of which I am quite attached. In opera, when protagonists are faced with an irretrievable loss or a dilemma that cannot be resolved, they often go mad. As ridiculous as the plots of operas can be, there’s some kind of truth and pathos in their use of madness.

In our domestic, neoliberally constructed lives we can confront these dilemmas continually: my iToy was made by slaves/I’m dependent on it; daddy does that thing to me/daddy says he loves me; if I love my partner I have to have sex with him/if he wants sex with me that means he loves me; a career gives my life meaning/a career is chewing up my life.

Unlike popular depictions of madness, it is rarely actually operatic. But the consequences of competing and conflicting states of existence can be devastating. And, of course, these are the states that neoliberal capitalism specialises in both creating and managing. These can take an infinite number of forms. After all, creating an endless variety of subjectivities is what capitalism specialises in.

They are always fractured subjectivities, or to use a DSM term: dissociative identities. Capitalism creates intense desire and insists those desires can only satisfied by engaging in a process of destructive and voracious acquisition that is both endless, and dependent on compliance and silence. Nobody orders us to compete in an increasingly punitive workplace, plunge into the wasteland of a 30-year mortgage, rear our children in fractured nuclear families and fill our lives with possessions made by slaves in countries we prefer to visit as tourists. But we do, largely because we often have little choice.

The DSM format of mental illness is one shorn of any political context. The idea that what is called ‘mental illness’ is actually an effect of ordinary, sanctioned practices of relationships, gender identities and economic worth is one that needs more attention. Those of us in what are sometimes called the ‘helping professions’ rarely consider that what we are doing in working with those designated as mentally ill is cleaning up the endless devastation caused by neoliberal capitalism and, not unusually, enabling a kind of pathological neoliberal framing and labelling of the helped. That is why behavioural cognitive-based therapies are so attractive to politicians and functionaries of the neoliberal state; it avoids any analysis of the context around the diagnosed condition, it gives them an out in demonstrating their compassion, and promises a definite quick fix, like sending a car to a mechanic.

In his new essay-length book Strictly Bipolar, Darian Leader points out that the surge in diagnoses of bipolar disorder ‘occurred precisely when the patents began to run out on the biggest-selling mainstream antidepressants in the mid-90s [and] bipolar suddenly became the recipient of the vast marketing budgets of the pharmaceutical industry’. The diagnostic mechanisms of the DSM dovetail neatly with the massive US insurance and pharmaceutical industries.

The designation ‘mental illness’ is also a way that those working in the field of mental health can use to manage out their perceptions of trauma, of the terror that interacting with the distressed can bring, and nullify any political causes. Trauma has of course, a traumatic history. And part of that history is trauma’s ineluctable links to the political, links that are often effaced or forgotten.

The history of trauma’s descriptions – hysteria, melancholia, nerves, shellshock – are all linked to oppressive cruel social orders: misogyny, child abuse, war, colonial occupation, neoliberal economics and so on. To trace the etiology of trauma is to map the history and topology of social unrest, oppression and political cruelty. ‘Is mental illness culturally determined’, the Guardian cautiously asked last week, positing a question that Frantz Fanon chewed up decades ago.

Physical trauma is a wound; a damage to tissue. The physical organism has been breeched. When we talk about (what is termed) ‘psychological’ trauma, something else has been breeched, something difficult to quantify.

What has been damaged is the sense of meaning-making – the actual building blocks of one’s personal experience; the thinkable-about, the dreamable-about, the actual way we remember things. This is the membrane that contains us.

Something breaks down as though a violence has happened internally as well as externally. Nothing is predictable anymore. There has been an internal loss as well as an external loss. What was coherent internally is now fragmented and chaotic and terrifying.

What has happened becomes unspeakable via the primary method of symbolising language. It gets spoken in other ways, a so-called ‘symptom’. Of course these take many diverse forms. In the introduction to his lecture ‘Air War and Literature’ contained in his book On the Natural History of Destruction, WG Sebald wrote of the affect that the Allied bombing of Germany had on his writing. Sebald was born a few weeks before D-Day; that is, after the firestorm of Hamburg but before that of Dresden.

I am one of those who remained almost untouched by the catastrophe then unfolding in the German Reich [but] I tried to show, through passages of some length taken from my own literary works, that this catastrophe had nonetheless left its mark on my mind.

The staggering numbers of traumatised US combat veterans, dumped back in the middle of the most rapacious neoliberal economy on earth, is both a reality and a metaphor for how capitalism creates and discards its subjects. The trauma experienced by US combat vets is of two orders: first, there’s the overwhelming psychological trauma produced by continual states of terror and hyper-anxiety and exposure to, or commission of, the bloody destruction of other human beings. Second, those recruited for the patriotic wars against freedom-haters often really believe that’s what they are doing – making the world a purer place by killing bad guys. The realisation that their struggle against evil was actually a meaningless slaughter for the benefit of a few oligarchs or multinationals can be unspeakably bitter and again contribute to that bicameral state of mind I mentioned earlier: my country is the greatest nation on earth/I murdered children in its name.

I’m not arguing that combat vets routinely experience epiphanies into the dark heart of capitalism. But the pernicious thing about capitalism is that the only way to come to understand one’s complicity with it is to gain an understanding that is, in a sense, traumatic.

There is no DSM of Normal States. In fact a desire to have one would probably be worthy of a category for DSM-6. But in definitions of madness there is always an implicit idea of the normal. It’s just that no-one ever says what it is. Mostly that’s because no-one knows what it is. But everyone pretends – or perhaps ‘conspires’ would be a better verb here – to know.

Lacan said one can only be neurotic, psychotic or perverse. As interesting an idea as that is, the investigation of what might constitute versions of sanity, is something that could do with a better political grounding. The Left has historically had many omissions in its political projects, and it’s never been great with psychologies. But perhaps a discussion of what versions of sanity we could usefully inhabit could be one project to put on the table. There are endless descriptions of madness and almost none of sanity. One could argue that even the relentless categorising of madness is a kind of madness itself. It’s interesting to read the DSM as a madman’s dictionary, written by a kind of obsessive butterfly collector who broods endlessly on the dark minds of others, and attempts to build a master-template to describe them all, without omission. In other words the DSM reads like it was written by someone in the throes of a deep and irretrievable psychosis.

If ‘mental illness’ is actually a label we use to disguise the presentation of trauma and stop thinking about it, and one of the characteristics of a traumatised state is the struggle to think about the unthinkable from a state where the process of thinking has been ruptured, then perhaps a politicised sanity needs to recover the idea of thinking.

To talk about thinking is to learn to do it. And whatever it is you do when you are thinking will, by default, shape your definition. Thinking about thinking has a long history – and a long history of paradoxes too. How does the mind think about the mind? Is that like a finger touching itself?

To try and debate these things with someone is to want to tell them to stop thinking so much. Before you know it you’re bogged down in debates that make the Pinocchio Paradox look pretty simple. So rather than asking ‘what’s the definition of thinking’ and find ourselves arguing with people like John Searle, perhaps there’s a way we can outflank ourselves a bit, which after all, is the only way to engage with your own politics of who you are – try to find creative and attentive ways to see ourselves as others might.

Maybe thinking is tied up with the capacity to hold in our minds the minds of others; to think about the thinking of others. If that’s the case, then thinking is not just the ability to cognitively plan, to get from Brisbane to Melbourne or to build a better land mine. Anyone who considers that others have minds is never going to be able to rejoice in the construction of a more effective way to chop other living human beings into bits. One of the most unnerving characteristics of our political representatives is that they so often seem to demonstrate their lack of ability to consider others as persons.

One can only learn to think in the presence of other beings who think. No child is ever going to be successfully reared by a robot, even one that passes the Turing Test. One can mimic thinking, but it’s not really going to get you anywhere. The scary thing about the push for AI is not that we might actually get human intelligence inside a machine, but that we’ll get something that mimics it.

Of course, the capacity to hold the mind of another in your mind wouldn’t be the end of thinking, it would be the beginning. It would commit one to an ethic of more thinking, of working out one’s stance in relation to others, to be situated within politics: what is done and who gets to do it, what gets said and who gets to say it, what gets felt and who gets to feel it, who gets paid and who gets to pay them, what gets gendered and who gets to gender it, and so on.

Capitalism facilitates the cult of individuality and this is often posited as the antidote to fascism. But sovereign power requires the eradication of plurality, not individuality. Of course a fascist political architecture also needs external structures to make it possible; compliant media keen to sensationalise and demonise, continual surveillance of the population, civil liberties available to only a few, continual war or the threat of war, a population disillusioned with the protocols of democracy, resurgence of a militarist nationalism, creation of a series of internal threats to the nation etc. The injunction of the fascist is not only Do Not Think, but also a demand that the subject substitute primitive ideologies and desires instead.

Whenever ‘thought’ is required it is instantly expelled into a demonic other: Jews, Muslims, teenagers, women, refugees etc. The fascist is always paranoid and if there’s one thing that can be said to characterise political life post-9/ll and post-financial crisis, it’s paranoia and the demand that we leave thinking to others.

Overland is a not-for-profit magazine with a proud history of supporting writers, and publishing ideas and voices often excluded from other places.

If you like this piece, or support Overland’s work in general, please subscribe or donate.

Stephen Wright’s essays have won the Eureka St Prize, the Nature Conservancy Prize, the Overland NUW Fair Australia Prize and the Scarlett Award, and been shortlisted for several others. He was writer-in-residence for the 2015 Mesmerism new music festivals. In 2017, he won the Viva La Novella Prize. His winning novel, A Second Life, was published by Seizure, and also recently won the Woollahra Digital Literary Prize for Fiction.

Comments

V. interesting. The Left has usually ignored psychologies – except as potential tools of socialisation – or confused them with personal moralities. But any political action requires conversation,and therefore listening, and listening can be a profoundly disruptive and enlightening act. When we listen to someone with a political stance (listening for who and what could be speaking and how) we can hear the most extraordinary things.
The fascist privileges words as concrete units. The DSM doesn’t require a listener at all. It’s in many ways the template of the neoliberal conversation. Meaning is predetermined, and allocated by the most powerful party, about the other’s state of mind.

This thinking about thinking stuff is always tricky, but I’ll risk a thought here.

Leader’s lockstep mental processing of the individual paranoiac – fault, name, message – applies also to terrorist groups and armies etc (all forms of fascism) who would think somewhat alike I presume, but I wouldn’t call that thinking in the terms expressed here. Pretty horrible if it is: to think through to and enact the destructive violence of the message on the other. That’s the point I take it of thinking that holds the other in mind: how could such violence be enacted if the other were being held in mind. I’m guessing then that the sort of thinking that holds the other in mind could never be an invention of one’s own mind, that all would be lost if the other were in any way a fiction.

That to me is the problem: the eradication of all fiction in the mutual passage between self and other.

The title of the post appears to have changed overnight. Or maybe I dreamed it. Or am in the early stages of a DSM psychosis.

Breivik’s paranoia is a politically-inspired one. It’s structure that echoes that of the public messages being broadcast by politicians etc over the previous decade. For example John Howard: There are bad things out to get us and destroy our Australian life ; they are called refugees; we must intern them forever so they can’t infect us.

Also a necessary part of this fascist paranoid discourse as Jeff Sparrow points in his current piece, is the demonisation of the other. The other has to be reduced to an object, and DSM typologies do this well, reduce people to a series of identical conditions’ that can be fixed by medication or behavioural interventions. Which explains why institutional psychologies have been often great supporters of fascist regimes.

Yes and the discourse is a two-way street. It’s difficult to conceive of terrorism (politically inspired, or simply random acts of violence) without the disseminating power of mass and social media, as that’s what terrorisms seems to be: the conscious and planned production of an event so that mass and social media will magnify and amplify that event. So the living bodies that are maimed and killed are conceived not as bodies even, but as messages for the other.

It does appear so, but why should violent fascist paranoias get inscribed within masculinity rather than femininity? I was trying to suggest that if selves construct others as fictional in any way the game is up, and identity formation through fiction does appear to happen differently for males and females due to cultural conditioning, in that males are more likely to identify with and imagine themselves as the hero figure, and by extension mirror the same process in life by identifying with the position of a particular type of ‘heroic’ male other. If that scenario has any credibility, it depends on which hero types are identified with as models of male development. In short, the reading or viewing of male-oriented stories can reinforce a particular type of gender identity which is carried over into the social arena. A bit sketchy, and a big jump. I know.

As far as masculinities go, we’re looking at a potent mixture of class, poverty, the collapse of certain types of white male power, and closed rigid identities (your stories of male heroes) and the continued foregrounding of neoliberal ideas of failure and success, and the political paranoias that expunge the causes of failure into others.
On top of that consumer capitalism sends everyone a bit mad. Also, add guns

Ah, but I was trying to consider why masculinity in particular gets inscribed with violent fascist paranoias rather than femininity, and I agree there is more than I came up with, but why should the cocktail suggested produce violent paranoid men and not so much women, considering women too are beset by class, poverty, closed rigid identities and the continued foregrounding of neoliberal ideas of failure and success. Perhaps there is no specific answer other than roleplaying as a result of gender naturalisation?

I’d be interested to hear what you have to say about Borderline Personality Disorder (BPD) in light of your understanding of how the neoliberal capitalist society pathologises certain behaviours. One of the classic ‘symptoms’ of BPD is having multiple sexual encounters, usually seen to be a sign of an inability to maintain lasting, meaningful relationships. This already carries its own typology, in that it is seen as a negative trait and one that defines or at least circumscribes a disorder. I’ve been reading about Stoicism, and the long history thereof. As a person who fundamentally resists ‘positive thinking’, I’ve begun to make a few connections, between the ‘hype’ of success and the prevalence of ‘mental illness’, in a society that is geared towards creating drones to feed the human resources, and their necessary marginal others. It’s not surprising then, that the incidence of BPD has grown to 20% of the population. In the 1970s, sexual ‘promiscuity’ was viewed as an element of women’s liberation; now, it is a patholigised/negative ‘symptom’ of a mental illness. What makes me even more angry is the fact that Facebook continues to allow pages dedicated to the abuse of women in an age, apparently, when having ‘casual’ sex is a symptom of an illness but violent misogyny is acceptable.

Interesting question. The thing about borderline personalities is that they are borderline, existing on the margin between neurosis and psychosis, neither one nor the other. In other words, (it seems to me) it’s a categorisation of conditions that can’t be categorised. That’s interesting to me because I think many ‘disorders’ need fuller descriptions that require the active participation of the ‘disordered.’ I do a lot of counselling/psychotherapy with people who have suffered severe childhood trauma, who are often afraid they can be labelled as ‘mad’ in some way – and sometimes have been. A description of their experience that is collaborative, non-diagnostic and creates a new and shared and personal vocabulary can be immensely helpful.
In the book I mentioned in the post, ‘Strictly Bipolar’, Darian Leader makes the point that many of the characteristics of bipolar are exactly the virtues we are exhorted to display be neoliberal politics. Consumer capitalism makes people ill and destroys our capacity to have functioning and responsive interior lives.
I didn’t really have time or space to go into gender biases in mental illness. But of course women are always likely to be labelled as promiscuous than men and the history of DSM psychologies is often of men diagnosing women. In her book ‘Mad Men and Medusas’ the feminist writer Juliet Mitchell talks of a borderline state that she equates with the mythology of Don Juan. It’s a state characterised by compulsive falling in love, a hysteria driven by romance’s tropes of fusion and compulsion, but either way the other becomes a kind of object of investment that either exalts one or destroys one.

Oh to be categorised. Today I read in the tabloids – I subject myself to the ‘weeklies’ every week as a kind of punishment, or lesson – that Bec Hewitt thinks she has OCD. What a cruel toss of the dice! She has a compulsion to clean her mansion, in the Bahamas (and she’s not seeking treatment but she’s so brave in speaking about it). I met a boy with OCD (aged 20) who was a talented piano player who wore plastic gloves because he wanted to cut off his hands. He was institutionalised. He would draw lines of blood across his wrists; he wanted to excise his hands, the very thing that gave him joy. You’re right Stephen, and this is a lovely and heart-rending sentence: ‘Consumer capitalism makes people ill and destroys our capacity to have functioning and responsive interior lives.’ I always look back, to Charmian Clift, to Frida Kahlo, Christina Stead. Nostalgia, however, is as crippling as any ‘mental illness’. Where to, from here?

I always think of OCD as one of the ways that people try to hold themselves together when things are falling apart.
I think as far as ‘where to’ that not subscribing to DSM-type categorisations and finding new vocabularies to describe what people are experiencing can be really useful. And also, as I’m suggesting, thinking about what ‘sanity’ or rather ‘sanities’ might look like – and not in some kind of moral sense, but in a political sense. For me that’s more about digging into what I already think. So (for example) if I think that gender violence is very much an urgent male issue, what does that say about what I believe about human beings, about what they deserve, and how they are made and so on.

I fear, however, that in trying to pose an alternative view of “mental” health and illness to that of the (failed) DSM model, you fall into something of the same trap as its authors do — to try to explain things too directly from underlying causes (for you social, for them biological), and/or to treat directly observable phenomena (trauma, war, cruelty, individualism, “neoliberalism”, psychiatry itself) as themselves more fundamental and essential than they really are (when the mainstream psychiatrists tend to treat biological phenomena in the same way).

If we step back a bit, medicine (and healthcare more generally) under capitalism rests on a tension between a more general quest for explanation and healing of individual states that are considered to be “ill”, and the way that this is organised as part of the social relations of the capitalist mode of production. As a result there is a constant social struggle over the meanings of what health and illness are, because those meanings reflect (in a mediated way) wider social contradictions and conflicts. This social construction of meaning is as present in “physical” medicine as it is in “psychological” medicine, although in the latter the political aspects of this seem more obvious because they impinge more readily on dominant conceptions of society. Thus, to understand psychiatry in a way that is not one-sided (i.e. either as a “good” “objective” science in the positivist sense or a “bad” “politicised” method of social control in the anti-psychiatric idiom) you have to actually grasp the profession’s own political economy within a wider political economy of capitalism, with all the contradictions that implies. That, at least, allows us to politicise mental health and make positive demands for reforms as part of a project of social transformation (rather than a project for the reform/destruction of psychiatry in isolation). This politicisation I think is missing from your critique.

On the question of the Left and normal psychology: The problem that many mainstream and radical views of psychology share is that they both start from trying to explain individual consciousness (or subjectivity) as a fundamental unit of analysis, mainly because it appears so phenomenally, and then seek to understand what has gone wrong in its functioning. One pole reduces breakdowns in consciousness to “faulty brain circuits” while the other pole reduces it to “faulty social organisation”. Neither considers the possibility that individual consciousness is itself the product of the social totality, a totality that is unavoidably built from a biological substrate but not reducible to it. To put a modern spin on Voloshinov, perhaps the individual psyche is best conceptualised as a boundary phenomenon between biology (nature) and social organisation. Therefore while we can critically deconstruct on what the meaning of sanity and insanity is within existing capitalist social relations, in terms of posing an alternative “true” sanity we have to be careful not to define its meaning too narrowly. What makes us uniquely human is that psyche which develops from our ability as a species to transform nature and our social relationships through productive activity. This suggests a potential for much broader ways of thinking if we collectively construct different social relations for ourselves, even while having to use our existing (fractured, capitalist) psyches. Ways of thinking that will no longer be hemmed in by the exigencies of the existing social order, but will not be realisable until our collective self-activity has created the conditions of their possibility.

[Disclaimer and invitation for accusations of crimes against humanity: I work as a public hospital psychiatrist.]

Tad, with respect I doubt if mainstream psychiatry is able to be reformed. I think a broader menu of social transformation would try to dispense with psychiatry altogether and find other ways of speaking about human beings and social problems. Sure there may be ways that the current system could be more ‘humane’ but it’s a stop gap measure, a bit like disaster relief. And imperial US psychologies – which I think is a very politicised way of describing psychiatry – are not something we need to try and ‘reform’ anymore than I’d try and reform drone strikes.
I have no problem with the idea of the self as a kind of marginal (and highly problematic) phenomena at the border of biology and social organisation, but I think that the state of or nature of consciousness is a bit beyond the remit of Overland. I’ve gone there once or twice, but I don’t think it’s really a fruitful endeavour here.
i’m not allying my arguments with those of the historical anti-psychiatry movement, but positioning psychiatry very broadly as a way that imperialism and neoliberalism still play out their creation and policing of subjectivities.

“I think a broader menu of social transformation would try to dispense with psychiatry altogether and find other ways of speaking about human beings and social problems. Sure there may be ways that the current system could be more ‘humane’ but it’s a stop gap measure, a bit like disaster relief.”

This strikes me as untenably idealist (in the philosophical sense) and abstract. We live in a world where distress, pain, inability to cope, complete breakdown, etc., are part of our experience and the battle over whether certain “stop gaps” are better or worse is part of wider social and political struggles. Perhaps as a thought experiment one might try to imagine something outside this, but it will only be a thought experiment thoroughly shaped by the concrete experience of living in the current world with its current contradictions.

Marxists have often argued that transcendance of capitalist social relations requires fighting for higher wages (lower rates of exploitation) in the service of getting rid of wage labour (and exploitation) altogether. With healthcare in general — all of which is, after all, a form of “stop gap” and “disaster relief” while concrete human beings continue to embody capitalist social relations — we cannot avoid riding a similar contradiction, because there is nothing beyond it until we make a beyond with the tools we have at our disposal in the here and now.

By labelling mainstream psychiatry as “imperial US psychologies” and talking of “policing” of subjectivities, I still think you capture these phenomena one-sidedly and credit imperialism (or neoliberalism) with too much uncontradictory power. Indeed, there’s an instrumental view of psychiatry in your account that suggests that if we only threw off these shackles imposed on us from above we could think more clearly, yet those shackles are painted as all but unbreakable. Mainstream psychiatry does indeed play a deeply problematic role but it is more in terms of its embeddedness in existing social power relations than any kind of primary role in imposing them. Indeed, the fractured subjectivities that capitalism undeniably produces are not simply a way the system controls us; they also undermine the ability of capital to expand because they damage the real human beings who are essential to that self-expansion.

I also think your position misses both how much our existing practices at every level of society shape our thinking, and how the contradictions in the social relations that are embodied in us provide the possibility of transcending those selfsame social relations. In that sense, there seems to be a kind of pessimistic voluntarism in the way you approach the issue. It is unclear to me how this can help guide political action.

(Happy to leave off the consciousness issue for now — I was trying to respond to your argument about the Left and normal psychology, which inevitably heads down this path.)

I imagine that a psychiatrist might well find my position idealist. If psychiatry were reformable it would have been reformed. 100 years is long enough.
I’m not advocating a thought experiment at all. I think there is room for a bit of guerilla action from within the systems of mental health, but like much contemporary political action (and we may well disagree what ‘political action’ is I suspect) I think it’s guerrilla action from within a catastrophic system that is barrelling down toward a catastrophic collapse. I’m not dispensing with stop gap measures, merely stating that we need to recognise them for what they are. Looking for ‘reform’ within a collapsing and unworkable system seems to me to be beside the point.
My arguments might seem abstract because I’m not proposing any utopian or reformist solution. If I were writing a manual for mental health workers it would be a manual of contingent guerrilla action not a manual for reform.
The situations we find ourselves are precisely because capitalist imperialisms and so on don’t care about contradictions within their structures and modalities of constructing subjectivities. Capitalism doesn’t care whether it will destroy it own subjects, because it counts on making new ones. It doesn’t work like other systems. That’s the difficulty with it. The tensions you see are not tensions.
And I profoundly disagree that psychiatry has just played some kind of non-dominant role, non-primary role in defining neoliberal relationships. That’s letting it off the hook in a major way.

Thanks for the very interesting article. I was struck by a number of lines, such as this:

One could argue that even the relentless categorising of madness is a kind of madness itself. It’s interesting to read the DSM as a madman’s dictionary, written by a kind of obsessive butterfly collector who broods endlessly on the dark minds of others, and attempts to build a master-template to describe them all, without omission.

Actually, I tend to think that psychiatry and psychology are perverse, in a very Sadean sense.(‘Frenchmen, one more effort, if you want to be Republicans!’). The presumption is that if one follows certain conventions of form and language(regarding diagnosis, experimentation, or whatever), then one is doing legitimate science (or medicine, or ‘help’), quite irrespective of the content. It’s a case of ‘One more DSM, if you want to become scientists!’. The failings of the DSM are epistemological and ethical as well as political.

Nevertheless, even non-psychiatric interventions – like cognitive behaviour therapy, for instance – tend to be coercive, normative, and alienating. (See this program, for instance, intended to root out ‘bad’, delinquent thought: http://m.nber.org//papers/w19014?utm_campaign=ntw&utm_medium=email&utm_source=ntw ). The fascist is generally content to control mere bodies; contemporary psychology and psychiatry wants to control minds. All of this is embedded in discourses of health, consumption, ‘wellness’, etc.

Lacan said one can only be neurotic, psychotic or perverse. As interesting an idea as that is, the investigation of what might constitute versions of sanity, is something that could do with a better political grounding.

I’m glad to see that you invoked Lacan. Lacanian psychoanalysis is one of the only – if not the only – non-coercive treatment available. In contrast to psychiatric attempts to bludgeon norms into people, it aims to address individuals’ modes of desire an enjoyment. Subjectivity may be limited to three broad categories, but its specific manifestations are infinite.
In the Lacanian account of things, subjectivity is not reducible to circumstance. After all, different people will respond to the same trauma differently. The wealthiest, most-privileged members of our society still sometimes suffer from crippling neuroses and psychoses. Nonetheless, in this paradigm, diagnostic categories are not ahistorical entities, divorced from social context. Fragmentation (and its corollary, psychosis), is increasing, notwithstanding the explosion of dubious diagnoses (as pointed out by Darian Leader, for instance). It’s not coincidence that, in a society in which ‘Enjoy!’ is arguably the principle imperative, so many are depressed.

There are, in my view, some clear starting points to viable alternatives to the DSM model. Some cursory ideas: treatment without coercion (except when there is immediate risk of homicide); proper comprehension of the epistemological status of psychiatry/psychology (i.e. that it is strictly pre-scientific, and owes as much to the humanities as to science); repudiation of the imperatives of capitalism (or Sovietism, or religion, etc); and consideration of the historical context in which subjectivity arises.

Thanks for this David. I’ve invoked Lacan a few times at Overland, partly because in its politics the Left tends to overlook (or rather completely ignore) the political structure of desire, as though desire were in some kind of moral category or could be equated with ‘feelings.’Capitalism is very much a modality of structuring desire, and a Lacanian Left is long overdue.
But also I use Lacan because as OL is a literary journal, Lacan thought Joyce’s ‘Ulysses’ was the work of a psychotic, and if anyone has dominated 20thc literature its Joyce.
As you say ‘the imperative to ‘Enjoy’ (which I also wrote about somewhere) is inextricably linked with the presentations we see labelled ‘bipolar’ or ‘psychotic.’ Consumer desire is fixated on ‘happiness’, a state delineated by mood. There are so many terrible psychic dilemmas that neoliberal capitalism facilitates and often grounded in a fragile and pernicious version of compliance. Diagnoses are increasing for many reasons, but also because so many more people are being made really ill, children included (see spectacular increases in ADHD and Autism ).
Ta for the alternative to standard psychiatry. I think this version of sanity (if I can call it that) has the virtue of being collaborative, politicised and interrogatory of DSM strictures.

The trend towards labelling / diagnosis, especially in children, is worrisome especially when you consider the investment / agenda of the thriving pharmaceutical industry and the way in which disorders are changed / tweaked and created. Autism is one example of a disorder that is on the rise, not necessarily due to inherent factors but because more children are being labelled as sitting in the autism spectrum. In the space of 12 months, Autism rates have risen from 1 in 88 children, to 1 in 50. ADD and ADHD were popular diagnosis in the 1990s but strangely, this is classed as a childhood disorder which must miraculously correct itself once a child turns 18. That is the age when the diagnosis no longer applies and medications are stopped, supports withdrawn, leaving a generation of medicated kids, mostly boys, to navigate the world without the drugs that kept their ADD in check through childhood. Not sure if this has any link to adolescent male crime rates, mental illness but it seems like a fair assumption. Not sure if you caught Dr. Allen Frances on Lateline the other night, but his argument that the DSM 5 turns normal behaviour into mental illness is worth a listen. http://www.abc.net.au/lateline/content/2013/s3763502.htm

Yeah, it’s been one of the popular criticisms of the DSM that it pathologises ordinary mood states, or idiosyncrasies.
I’ve worked a lot with autistic children (and now with some autistic adults) particularly 6 years and younger, and it seems very clear to me that diagnoses of children for any disorder are often a label on what we might describe as the child calling for help for the entire family.
In regard to childhood ADHD: just lately in my professional work I’ve come across men who have been diagnosed in adulthood (by their GP) as having had ADHD in childhood and then medicated as adults for the condition they used to have as children.

Really like this article….and not just because you have mentioned my name in it! I assume you have read that classic book ‘Trauma and recovery’ by Judith Herman? It makes many of the same links between politics, oppression, trauma and distress. Entirely agree that psychiatry has had its day and I may be naïve, but if its foundation stone, the classification system, is publically admitted by some of the world’s most senior psychiatrists to be ‘scientific nonsense’ and ‘not valid’, it is not clear to me how long the whole enterprise can survive. Alternatives clearly have to be based on making meaning – and including social and political contexts in those meanings. I’ve discussed some of this in my blog on http://www.madinamerica.com – an excellent site which I guess you already know about but which is highly recommended if you don’t.

Hi Lucy Johnstone, thanks for dropping by. Classical psychiatry has its claws firmly in the insurance and pharmaceutical systems and I guess that will be where it draws its resistance from. We shall see. I’m familiar with Herman’s book and some more, as I do counseling/psychotherapy with traumatised adults (and some children) who routinely present with diagnoses (bipolar, anxiety, psychosis, depression) often given by GP’s, some times by psychologists, but who have histories of complex trauma which no-one has ever thought to even discuss never mind link with their current state. madinamerica has some excellent examples of activism on it and a link to an Australian report which I was remiss in not linking to, but didn’t know you had a blog there. Ta. Good luck taking on the DSM disciples.

Your article resonated strongly with some of my own ideas about trauma, capitalism and the medicalization of every aspect of our lives. I have my own history of childhood trauma and the best therapy I have found up until now has been and I’m sure will continue to be music, poetry and writing that comes from the inner realm of another sensitive human being.Thanks Steve your article has been very helpful.

No worries. Childhood trauma is so common isn’t it? I always think that having to engage with psychotherapy is a sign of a social failure; the conversation the distressed person wants to have they haven’t been able to have elsewhere. If we had a less, lets say neoliberally-inclined social order, (and that covers artistic production too) a more extensive meaning-making that doesn’t blame or pathologise might be able to take place in ordinary life. Still, even with the weird systems we have people find all kind of ways to heal themselves quite well, without having to go to mental health professionals. And I think that writers can really speak to that in their work.

Well, yes, they go together. If on is doing the first, one is stepping out of the mental health paradigm into something else, which is I guess the creation and inhabiting of a new and singular language.

“Wilhelm Dilthey at the start of the 20th Century held that in spite of utter diversity, “anything human is in principle understandable,” if we enter into the other’s experiencing with our own. The two are not the same but they enrich each other.”
(http://www.focusing.org/gendlin/docs/gol_2168.html)

Well, I dunno. The whole point of coming up with philosophical and psychological theories is so that human beings can explain themselves to each other. Or ourselves to ourselves. We don’t even know why we individually do what we do half the time. I’ve done a zillion things that I can find no rhyme or reason for. All I can come up with is a best guess. Anyone who can explain themselves to themselves 100% the time is probably lying. Or was an author of the DSM.

I think it’s possible to get some deep intuitive sense of the other’s inner life, similar to the transference and counter-transference in psychotherapy; but this in a sense a doorway to the strangeness of the other, a strangeness which has to unseat us a little I think.

Regardless of the, at times, remarkable passage of this piece, and at other times the laughable attempts to derail its passage, I’m going along still with the idea that “the capacity to hold the mind of another in your mind” is the nexus of the piece, and hold to the idea still that the other can’t be in any way a fiction or part of the imagination of the othering person, and that othering in the Wright sense is a positive othering (obviously), unlike the negative othering where an other with a mental illness, for example, usually has negative perceptions in the eyes of whoever is doing the othering, and so perceives themself to have a deficient default identity to overcome.

Rather, and I’m leaning on the philosophy and poetry of Wallace Stevens a bit here, “the capacity to hold the mind of another in your mind”, involves removing all cultural and personal expectations and dogmas that might usually be projected onto the other (using the same example – a person with a mental illness), holding and seeing instead in your own mind whatever poverty or impoverishment there may be in the mind of the other – physical, mental or spiritual – in a positive light.

I know I’m adding and saying little here, and take it or leave it, that’s what I make of what I take to be the most important passage of the piece.

I’d probably pick apart the term ‘positive’ here. First, I don’t think anyone can remove all cultural etc expectations. I’m more concerned with being confronted with the mnd of another and being able to tolerate its experience, precisely because of what it evokes in you, because of its difference and unsettling nature. White Australia has a long history of not being able to tolerate others and mentally and physically expelling them, either by banishing them (reserves, homes, detention centres) and/or deriding them, and binding ourselves to other nations and ideologies that do the same. We are a nation always flirting wth fascist states of mind.

Yes, I can see the resistance to ‘positive’, and baulked a bit myself when I first wrote the word (but after that it didn’t worry me), and I was thinking too of the commenter who brought Lacanian analysis into the discussion, saying that it was the only non-coercive form of analysis, and although I don’t quite see Lacanian analysis in that way, I see other forms of analysis being death-oriented, and Lacanian analysis as tough and life affirming, in the sense that it is a question of the analysand rewiring desire and channelling negative and destructive inexperienced desires into experienced positive desires. That was the ‘positive’ I was holding in mind, but didn’t state, when writing the word, if that makes any sense.

I’ve got an old issue of Meanjin (2004) themed ‘On psychology.’ There’s an essay in it by a Lacanian analyst from Melbourne, Esther Faye. As part of her training she, of course, underwent a Lacanian analysis:

“In the process [of analysis] something happened to my desire; it shifted from being solely that of the hysteric, demanding answers to pressing personal questions, to that of the analyst, making a gift of my desire to the analysand, who comes to me with his or her own pressing questions….Lacanian psychoanalysis refuses to subscribe to the dominant psychotherapeutic tendencies of leading the patient towards acquiring the Sovereign Good…..rather than plugging the hole, stuffing the gaping mouth of demand (as the myriad products of capitalism do) the treatment is directed to keeping desire open…in short [a Lacanian works to] the ethic of ‘well-saying’ rather than well-being – that is, of saying as well as we can what we have been made from, how we have come to be.”

That’s well put. I think I saw and looked through that journal once, when my daughter was doing a uni essay. And you see the same sort of thing in other arenas too. Take Jamie Oliver, (I know, I know) for example, who went into British schools, saw that government funded canteen food was a disgrace, and set about transforming the desire of the students: from eating only fatty, unhealthy, deathly fast food through inexperience, to actually enjoying and preferring more life building foods after accepting and going with the gift of Oliver’s more experienced desire. Once turned on to and by Oliver’s more experienced desire, a lot of students ended up spitting out the once much-loved Turkey Twizzlers in disgust. At least that’s what I saw on late night tv just the other night.

Under-stand could be to be-amongst-those-standing.
Unsettle is to un-seat, or not-longer-sitting-down.

So they can work together. To understand is to be amongst those standing, which has some movement and agency and others-in-motion about it. And to do this, we need to unsettle what has settled. To sit down and expect the others standing to come to us — if we haven’t already driven them off our now settled land, or indeed killed them — this leads to no understanding.

I just finished Jonathan Shay’s ‘Achilles in Vietnam’ about the combat trauma of Vietnam vets. In an interview, one of the vets says to Shay how important it was to think of the Vietnamese as ‘gooks’ and ‘slopes’ – because otherwise, he continues, if we thought they were like us we couldn’t kill them.

The thing about the DSM is that once you read it, you realise that you meet most of the conditions for everything most of the time.
It would make a good party game; write down your 5 greatest anxieties on a piece of paper. Put them in a hat with everyone else’s. Then read each person’s (anonymous) list out 1 at a time, and diagnose. Then everyone gets to match up the diagnosis with the person. Whoever wins (gets the most matches) gets the most dessert.

A society in which any GP can diagnose anyone with a mental illness — since the mental illness bible lists every state and symptom possible — and proceed to subscribe drugs made by companies with mono- and duo-polies… sounds like a great Orwellian novel.

“It is proposed that happiness be classified as a psychiatric disorder and be included in future editions of the major diagnostic manuals under the new name: major affective disorder, pleasant type. In a review of the relevant literature it is shown that happiness is statistically abnormal, consists of a discrete cluster of symptoms, is associated with a range of cognitive abnormalities, and probably reflects the abnormal functioning of the central nervous system. One possible objection to this proposal remains–that happiness is not negatively valued. However, this objection is dismissed as scientifically irrelevant.”